GW1--06520_Well Construction - GW1_20241104

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WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only: •
1.Well Contractor Information: 1
Chris Morgan •
II.WATER ZONES I
;
WellContiactorName FROMO DESCRIPTION!
3572A \fp S ft � , ) ft. I
ft. ft
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NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Morgan Well & Pump, I N C FROM TO DMMETER , THICKNESS MATERIAL
Company Name 0 ft. ,qne^ ft 61/8 in. sdr-21 PVC
/J /V��, C 16.INNER CASINGVVl OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 7 1 5-J FROM TO DIAMETER THICKNESS MATERTAT _
List all applicable well construction permits(Le.UIC,County,Slate,Variance,etc.) ft. ft. in.,
3.Well Use(check well use): ft ft. in.;
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural DMuunicipallPublic ft ft. in.
•
OGeothermal(Heating/Cooling Supply) .ylcesidential Water Supply(single)
ft it in.
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❑Industrial/Commercial • ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: 0 ft. 20 it, bentonite ' poured
OMonitoring ❑Recovery ft. ft. -
Injection Well:
ft-. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color hardness,soillrock type,grain size,eta)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21Remarks) ft l.� ft r,
4.Date Well(s)Completed:.101°(`4 Well]D# C�r ft. S ft. r°g(fM6
5a.Well Location: S7 ft ft
)00 ft. ��ft. 901 g :iu '.. .,i..
ac W1 ft ft. i
Facility/OwnerN a Facility A
ft. ft. N-O V 0 4 202 t
. LOOS (,fw in it ui Ann
Physical Address,City,and Zip ft ft h-;:.-.;::7,-;..'---. ;'-r `'.Yi.:-,� ✓s'
]IC ,(�.lJ o,n 24 q 1, l a 21.REMARKS D:`„•; �C/.3-
County� " Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35 .Si fl ( b N -n (-1 3 I-13 W ©/a1/
6.Is(are)the well(s): llPermanent or ❑Temporary Signature of Certified We ontrac. Date
By signing thisform,'hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I lNo I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.i'
repair under t121 remar lm section or on the back of this form.
23.Site diagram or additional well details'
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
• drilled:+ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (_✓`J (ft.
For multiple wells list all depths ifdierent(example:3@200'and 2@100) ) Submit this GW-1 within 30 days of well completion per the following:
)
10.Static water level below top of casing:
0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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11.BorehoIe diameter: 6 1/8 (m) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 '
12.Well construction method: rotary
24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,d rectpush,etc.) county environmental health department of the county where installed •
, FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
air Permit Program,1611 MSC,Raleigh,NC 27699;1611
13b.Disinfection type: granulated chlorine Amount: ( ,
Form GW-1 North Carolina Department ofEnvironmeotal Quality-Division of Water Resources i Revised 6-6-2018